Procedures of Choice for Resection of Primary and Recurrent Liver Metastases from Colorectal Cancer

Value and prognostic factors of repeat hepatectomy for recurrent colorectal liver metastasis

BACKGROUND

More than 50% of patients with colorectal cancer develop liver metastases. Hepatectomy is the preferred treatment for resectable liver metastases. This review provides a perspective on the utility and relevant prognostic factors of repeat hepatectomy in recurrent colorectal liver metastasis (CRLM).

DATA SOURCES

The keywords "recurrent colorectal liver metastases", "recurrent hepatic metastases from colorectal cancer", "liver metastases of colorectal cancer", "repeat hepatectomy", "repeat hepatic resection", "second hepatic resection", and "prognostic factors" were used to retrieve articles published in the PubMed database up to August 2020. Additional articles were identified by a manual search of references from key articles.

RESULTS

Despite improvements in surgical methods and perioperative chemotherapy, recurrence remains common in 37%-68% of patients. Standards or guidelines for the treatment of recurrent liver metastases are lacking. Repeat hepatectomy appears to be the best option for patients with resectable metastases. The commonly reported prognostic factors after repeat hepatectomy were R0 resection, carcinoembryonic antigen level, the presence of extrahepatic disease, a short disease-free interval between initial and repeat hepatectomy, the number (> 1) and size (≥ 5 cm) of hepatic lesions, requiring blood transfusion, and no adjuvant chemotherapy after initial hepatectomy. The median overall survival after repeat hepatectomy ranged from 19.3 to 62 months, and the 5-year overall survival ranged from 21% to 73%. Chemotherapy can act as a test for the biological behavior of tumors with the goal of avoiding unnecessary surgery, and a multimodal approach involving aggressive chemotherapy and repeat hepatectomy might be the treatment of choice for patients with early recurrent CRLM.

CONCLUSIONS

Repeat hepatectomy is a relatively safe and effective treatment for resectable recurrent CRLM. The presence or absence of prognostic factors might facilitate patient selection to improve short- and long-term outcomes.

Japanese Society for Cancer of the Colon and Rectum (JSCCR) guidelines 2019 for the treatment of colorectal cancer

The number of deaths from colorectal cancer in Japan continues to increase. Colorectal cancer deaths exceeded 50,000 in 2016. In the 2019 edition, revision of all aspects of treatments was performed, with corrections and additions made based on knowledge acquired since the 2016 version (drug therapy) and the 2014 version (other treatments). The Japanese Society for Cancer of the Colon and Rectum guidelines 2019 for the treatment of colorectal cancer (JSCCR guidelines 2019) have been prepared to show standard treatment strategies for colorectal cancer, to eliminate disparities among institutions in terms of treatment, to eliminate unnecessary treatment and insufficient treatment and to deepen mutual understanding between healthcare professionals and patients by making these guidelines available to the general public. These guidelines have been prepared by consensuses reached by the JSCCR Guideline Committee, based on a careful review of the evidence retrieved by literature searches and in view of the medical health insurance system and actual clinical practice settings in Japan. Therefore, these guidelines can be used as a tool for treating colorectal cancer in actual clinical practice settings. More specifically, they can be used as a guide to obtaining informed consent from patients and choosing the method of treatment for each patient. Controversial issues were selected as clinical questions, and recommendations were made. Each recommendation is accompanied by a classification of the evidence and a classification of recommendation categories based on the consensus reached by the Guideline Committee members. Here, we present the English version of the JSCCR guidelines 2019.

Survival after repeat hepatectomy for recurrent colorectal liver metastasis: A review and meta-analysis of prognostic factors

BACKGROUND

Frequent recurrent hepatic metastasis after hepatic metastasectomy is a major obstacle in the treatment of colorectal liver metastasis (CRLM). We performed the present systematic review to evaluate the short- and long-term outcomes after repeat hepatectomy for recurrent CRLM and determine factors associated with survival in these patients.

DATA SOURCES

An electronic search of PubMed database was undertaken to identify all relevant peer-reviewed papers published in English between January 2000 and July 2018. Hazard ratios (HR) with 95% confidence interval (95% CI) were calculated for prognostic factors of overall survival (OS).

RESULTS

The search yielded 34 studies comprising 3039 patients, with a median overall morbidity of 23% (range 8%-71%), mortality of 0 (range 0-6%), and 5-year OS of 42% (range 17%-73%). Pooled analysis showed that primary T3/T4 stage tumor (HR = 1.94; 95% CI: 1.04-3.63), multiple tumors (HR = 1.49; 95% CI: 1.10-2.01), largest liver lesion ≥5 cm (HR = 1.89; 95% CI: 1.11-3.23) and positive surgical margin (HR = 1.80; 95% CI: 1.09-2.97) at initial hepatectomy, and high serum level of carcinoembryonic antigen (HR = 1.87; 95% CI: 1.27-2.74), disease-free interval ≤12 months (HR = 1.34; 95% CI: 1.10-1.62), multiple tumors (HR = 1.64; 95% CI: 1.32-2.02), largest liver lesion ≥5 cm (HR = 1.85; 95% CI: 1.34-2.56), positive surgical margin (HR = 2.25; 95% CI: 1.39-3.65), presence of bilobar disease (HR = 1.62; 95% CI: 1.19-2.20), and extrahepatic metastases (HR = 1.60; 95% CI: 1.23-2.09) at repeat hepatectomy were significantly associated with poor OS.

CONCLUSIONS

Repeat hepatectomy is a safe and effective therapy for recurrent CRLM. Long-term outcome is predicted mainly by factors related to repeat hepatectomy.

Repeat hepatectomy for recurred colorectal liver metastasis: is it justified?

Purpose

Liver resection is considered the only curative treatment modality for colorectal liver metastasis. The recurrence rate after hepatectomy is >50%. Two or more hepatectomies are applied to treat recurred metastases. We assessed the efficiency and feasibility of repeat hepatectomy and analyzed the prognostic factors after a repeat hepatectomy.

Methods

In total, 248 patients were diagnosed with recurred liver metastasis between January 2003 and May 2016. Second and third hepatectomies were performed in 70 and 7 patients, respectively. The other 171 patients did not undergo a repeat hepatectomy. Clinical features were collected from the medical records. We analyzed survival rates of the repeat hepatectomy group and the nonrepeat hepatectomy group. We also investigated factors affecting overall and disease-free survival of patients who received a repeat hepatectomy using univariate and multivariate analyses.

Results

Median overall survival was significantly higher in the repeat hepatectomy group than in the nonrepeat group (83.0 months vs. 25.0 months, P < 0.001). The morbidity and mortality rates of repeat hepatectomy were 9.1% and 0%, respectively. Median overall and disease-free survival of the repeat hepatectomy group were 62.0 and 51.0 months, respectively. The number of recurred tumors was the only significant factor for disease-free survival (P = 0.029). None of the factors affected overall survival.

Conclusion

Repeat hepatectomy is necessary, effective, and safe for treating recurred colorectal liver metastasis. Repeat hepatectomy can be considered in patients with fewer than three recurred metastatic tumors.

Trans-arterial chemoperfusion for the treatment of liver metastases of breast cancer and colorectal cancer: Clinical results in palliative care patients

AIM

To evaluate the clinical value and efficiency of trans-arterial chemoperfusion (TACP) in patients with liver metastases from breast cancer (BC) and colorectal cancer (CRC).

METHODS

We treated 36 patients with liver metastases of BC (n = 19, 19 females) and CRC (n = 17; 8 females, 9 males) with repeated TACP. The treatment interval was 4 wk. TACP was performed with gemcitabine (1000 mg/m²) and mitomycin (10 mg/m²), administered within 1 h after positioning the catheter tip in the hepatic artery. Before treatment, the size, location, tumour volume, vascularization and number of liver tumours were evaluated using magnetic resonance imaging (MRI). Tumour response was evaluated according to the Response Evaluation Criteria in Solid Tumors guidelines.

RESULTS

TACP using gemcitabine and mitomycin for metastases from CRC and BC was performed without any serious side effects. The follow-up MRI showed a therapeutic response in 84.2% of the BC patients - stable disease 47.4% and partial response 36.8%. A progression was seen in 15.8%. CRC patients showed a therapeutic response in 52.9% of cases. A progression of the disease was documented in 47.1% of the patients with CRC. These data show that TACP in patients with liver metastases of BC leads to a significantly better therapeutic response compared with CRC patients (P = 0.042). The median survival time was 13.2 mo for the BC patients, which is significantly longer than for CRC patients at 9.3 mo (P = 0.001).

CONCLUSION

TACP for liver metastases of BC appears to be a safe and effective palliative treatment with improved outcomes in comparison to patients with CRC.

Colorectal cancer with liver metastases: Neoadjuvant chemotherapy, surgical resection first or palliation alone?

Colorectal cancer (CRC) is one of the commonest cancers with 1.2 million new cases diagnosed each year in the world. It remains the fourth most common cause of cancer-related mortality in the world and accounts for > 600000 cancer-related deaths each year. There have been significant advances in treatment of metastatic CRC in last decade or so, due to availability of new active targeted agents and more aggressive approach towards the management of CRC, particularly with liver-only-metastases; however, these drugs work best when combined with conventional chemotherapy agents. Despite these advances, there is a lack of biomarkers to inform us about the accurate management of the patients with metastatic CRC. It is therefore imperative to carefully select the patients with comprehensive multi-disciplinary team input in order to optimise the management of these patients. In this review we will discuss various treatment options available in management of colorectal liver metastases with potential guidance on how and when to choose these options along with consideration on future directions in management of this disease.

Selecting patients for a second hepatectomy for colorectal metastases: an systemic review and meta-analysis

BACKGROUND

Opinions on the suitability of repeat hepatectomy for patients with recurrent colorectal liver metastases (CRLMs) vary among studies. We conducted a meta-analysis to establish the criteria for selecting the best candidates for a second hepatectomy.

METHODS

Database and manual searches were performed to identify comparative or prognostic studies published up to October 2013. Outcomes of interest included disease characteristics, perioperative outcomes, and long-term survival after initial and second hepatectomies for patients with CRLM. Study quality was appraised using the Newcastle-Ottawa scale and a modified Hayden's score.

RESULTS

A total of 7226 patients from 27 studies were included. Recurrent CRLMs after initial hepatectomy were more likely to be solitary (RR = 0.86, P = 0.045), unilobar (RR = 0.60, P < 0.001), and smaller (WMD = -0.66, P < 0.001). Postoperative morbidity and mortality were comparable between initial and second hepatectomies (RR = 1.10, P = 0.191; RR = 0.78, P = 0.678, respectively). In high-quality studies, patients showed better survival after a second hepatectomy than those after a single hepatectomy (HR = 0.68, P = 0.022). Patients meeting the following six predictors survived longer after second hepatectomy: disease-free survival after initial hepatectomy >1 y (P = 0.034); solitary CRLM at second hepatectomy (P < 0.001); unilobar CRLM at second hepatectomy (P = 0.009); maximal size of CRLM at second hepatectomy ≤ 5 cm (P = 0.035); lack of extrahepatic metastases at second hepatectomy (P < 0.001); and R0 resection at second hepatectomy (P < 0.001).

CONCLUSIONS

Second hepatectomy is a safe and feasible procedure for patients with recurrent CRLM. In fact, in well-selected patients it improves overall survival. The established criteria can help clinicians to select the best candidates for second hepatectomy and to achieve better long-term outcomes after resection.

A systematic review of repeat hepatectomy for recurrent colorectal liver metastases

BACKGROUND

Selected patients with recurrent colorectal liver metastases (CLM) may be resectable by repeat hepatectomy approach. In this review, we aim to collate and evaluate the published evidence for repeat hepatectomy in patients with recurrent CLM.

METHODS

Searches of the Medline and Embase databases were undertaken to identify studies of repeat hepatectomy in patients with recurrent CLM focusing on the perioperative treatment regimen, operative strategy, morbidity, technical success and survival outcomes.

RESULTS

Twenty-two observational studies were reviewed. A total of 1,610 patients underwent second hepatectomy for recurrent CLM. The median percentage of extra-hepatic disease was 15 % (range, 0-39 %). Preoperative chemotherapy was reported in 5/22 studies. Major liver resection was undertaken in 25 % (range, 9-59 %) of patients and the R0 resection rate was 90 % (range, 77-96 %). Postoperative morbidity and mortality after the second hepatectomy were 23 % and 1.2 %, respectively. Recurrence rate after second hepatectomy was 63.9 % (range, 42-91 %) with a median follow-up period of 32 months (range, 19-59 months). Median overall survival was 35 months (range, 19-56 months). The 3-year and 5-year overall survival rates were 55 % (range, 11-82 %) and 42 % (range, 31-73 %), respectively.

CONCLUSION

Second hepatectomy is safe and feasible in selected patients with recurrent CLM and is associated with acceptable perioperative and survival outcomes. Future prospective studies are required to further define the patient selection criteria for repeat hepatectomy and the exact role of perioperative chemotherapy.

Repeat liver resection for colorectal metastases

BACKGROUND

Following resection of colorectal liver metastases (CLMs) up to 75 per cent of patients develop recurrent liver metastases. Although repeat resection remains the only curative therapy, data evaluating the outcome are deficient. This study analysed postoperative morbidity, mortality and independent predictors of survival following repeat resection of CLMs.

METHODS

Data on surgical treatment of primary and recurrent CLMs between 1994 and 2010 were collected retrospectively, and compared with those for single hepatic resections carried out during the same period. Independent predictors of survival were evaluated by means of univariable and multivariable Cox regression models.

RESULTS

In this interval 1026 primary resections of CLMs were performed and 94 patients underwent repeat CLM excision. Overall postoperative morbidity and mortality rates were low (15·8 and 1·3 per cent respectively), with no statistical difference in patients undergoing repeat surgery (P = 0·072). Compared with single liver resections, overall survival was improved in repeat resections (P = 0·003). Multivariable analysis revealed that size of primary CLM over 50 mm was an independent predictor of survival (hazard ratio (HR) 2·61; P = 0·008). Only major hepatic resection was associated with poorer outcome following repeat surgery (HR 2·62; P = 0·009). International Union Against Cancer stage, number of CLMs, age at surgery and need for intraoperative transfusion had no impact on survival after repeat resection.

CONCLUSION

Recurrent CLM surgery is feasible with similar morbidity and mortality rates to those of initial or single CLM resections.

Repeat hepatectomy for recurrent colorectal metastases

BACKGROUND

The oncological benefit of repeat hepatectomy for patients with recurrent colorectal metastases is not yet proven. This study assessed the value of repeat hepatectomy for these patients within current multidisciplinary treatment.

METHODS

Consecutive patients treated by repeat hepatectomy for colorectal metastases between January 1990 and January 2010 were included. Patients undergoing two-stage hepatectomy were excluded. Postoperative outcome was analysed and compared with that of patients who had only a single hepatectomy.

RESULTS

A total of 1036 patients underwent 1454 hepatectomies for colorectal metastases. Of these, 288 patients had 362 repeat hepatectomies for recurrent metastases. Some 225 patients (78·1 per cent) had two hepatectomies, 52 (18·1 per cent) had three hepatectomies, and 11 patients (3·8 per cent) had a fourth hepatectomy. Postoperative morbidity following repeat hepatectomy was similar to that after initial liver resection (27·1 per cent after first, 34·4 per cent after second and 33·3 per cent after third hepatectomy) (P = 0·069). The postoperative mortality rate was 3·1 per cent after repeat hepatectomy versus 1·6 per cent after first hepatectomy. Three- and 5-year overall survival rates following first hepatectomy in patients who underwent repeat hepatectomy were 76 and 54 per cent respectively, compared with 58 and 45 per cent in patients who had only one hepatectomy (P = 0·003). In multivariable analysis, repeat hepatectomy performed between 2000 and 2010 was the sole independent factor associated with longer overall survival.

CONCLUSION

Repeat hepatectomy for recurrent colorectal metastases offers long-term survival in selected patients.

Repeat hepatectomy for liver metastases from colorectal primary cancer: a review of the literature

INTRODUCTION

After hepatectomy for metastases from colorectal cancer (CRC), approximately 50% to 70% of patients develop recurrent hepatic metastases. This recurrence is limited to the liver in about one-third of cases. The purpose of this study is to report a comprehensive review of the literature concerning the results of repeat hepatectomy for recurrent liver metastases from CRC.

METHODS

An electronic literature search was conducted to identify all medical articles published concerning repeat hepatectomy for liver metastases of colorectal origin during the period January 1990 to December 2010.

RESULTS

After a second hepatectomy, the mean mortality was 1.4% and the mean morbidity rate was 21.3%. The 5-year survival ranged from 16% to 55%. After a third or fourth hepatectomy, the mean mortality rate was 0% and the mean morbidity rate was 24.5%. After a third hepatectomy, the 5-year survival ranged from 23.8% to 37.9%. After a fourth hepatectomy, the 5-year survival was 9.3% to 36%.

CONCLUSION

Repeat hepatectomy seems justified, since it may result in prolonged survival with acceptable rates of morbidity and mortality, results similar to those seen after initial hepatectomy.

Effectiveness and cost-effectiveness of peri-operative versus post-operative chemotherapy for resectable colorectal liver metastases

BACKGROUND

The role of neo-adjuvant chemotherapy prior to hepatectomy in patients with resectable colorectal liver metastases is currently a matter of debate. The aim of the present study was to analyse life-expectancy, quality adjusted life-expectancy and cost-effectiveness of the two chemotherapeutic strategies.

METHODS

A Markov decision model was developed, on the basis of parameters derived from an extensive literature search of the last ten years, to compare outcomes of peri-operative versus post-operative chemotherapy.

RESULTS

Life-expectancy observed for peri-operative chemotherapy was 54.56months and 52.62months with post-operative chemotherapy only; the quality-adjusted life-expectancy with peri-operative chemotherapy was 39.33 quality-adjusted life-months (QALMs) and 37.84 QALMs with post-operative chemotherapy. Peri-operative chemotherapy results in an increase in total costs of 1180€ over ten years and in an incremental cost-effectiveness ratio (ICER) of 791.9€/QALM. The model was more sensitive to the expected 3-year recurrence-free survival (RFS) and cost of hepatic resection: with respect to an expected 3-year RFS⩽25% the peri-operative approach was more cost-effective than post-operative strategy but differences in average cost-effectiveness were small. The relationship between ICER and cost of hepatic resection was inverse because the higher the cost of hepatic resection, the higher the cost saving due to patients becoming unresectable during neo-adjuvant therapy.

CONCLUSIONS

In the treatment of resectable colorectal liver metastases, the addition of neo-adjuvant chemotherapy could be cost-effective because it makes it possible to avoid hepatic resection in patients who do not respond to the neo-adjuvant approach; however, the life-expectancy of the two strategies is very similar.

Repeated liver resection for recurrence of colorectal cancer metastases

BACKGROUND

Resection of liver metastases is accepted as treatment for diverse tumours, implying a survival improvement. Metastases often recur after first hepatectomy and, very few would be potentially resectable.

MATERIALS AND METHODS

A retrospective study of 18 patients undergoing repeated hepatectomies (two or more liver resections in the same patient) due to metastases of colorectal cancer between 1988 and 2006 was performed.

RESULTS

Thirteen men and five women, mean age 57.55 years, participated. In all patients, repeated liver resection was performed due to recurrence of the metastases. Complications rate after first hepatectomy was 11.1% and after the second 16.6%. Mortality rate was 11.1% after second hepatectomy, and there was no mortality after third hepatectomy. Three- and 5-year survival after colectomy was 88.9% and 77.8%, respectively; after first hepatectomy 3- and 5-year survival was 88.9% and 61.1%, respectively; after second hepatectomy, 3- and 5-year survival was 83.3% and 61.1% respectively; and 3-year survival after third hepatectomy was 67%.

CONCLUSION

Repeated resections by expert surgeons for recurrent liver metastases can be safely performed, with low morbidity and mortality rates similar to first hepatectomies. Repeated resections of liver metastases of colorectal cancer improve global survival.

Hepatectomy for resectable colorectal cancer metastases--indicators of prognosis, definition of resectability, techniques and outcomes

The field of surgery for liver metastases is evolving rapidly. The proportion of patients viewed as amenable to resection is increasing with surgeons becoming more aggressive and systemic therapy more effective. Surgical resection is associated with low mortality and overall 5-year survival approaching 40%. Best candidates for resection are those with stage I or II colorectal cancer, fewer than 4 hepatic lesions, no lesions larger than 5 cm in diameter, no evidence of extra-hepatic disease, CEA level less than 5 ng/mL, and a disease-free interval of at least 2 years. Perioperative chemotherapy with or without biotherapies, in-situ ablation techniques, portal vein embolization, and staged hepatectomy have extended the indications without lessening the results of liver resection for colorectal metastases.

Intra-operative ultrasound for detection of liver metastases from colorectal cancer

OBJECTIVE

The aim of this study was to evaluate the accuracy of intra-operative ultrasound (IOUS) imaging in detecting liver secondaries at the time of primary colorectal surgery and to evaluate the impact of IOUS on patient management.

METHODS

Data from 167 patients with primary colorectal cancer who were admitted for elective surgery between January 1995 and December 2003 were prospectively evaluated and analysed. All patients underwent pre-operative abdominal ultrasonography (US) and computed tomography (CT), as well as IOUS. The final diagnosis of liver metastases was made by means of histological examination of either biopsy or surgical specimens. The sensitivities of pre-operative US and CT were compared with the sensitivity of IOUS, referred to histology. Changes in surgical management owing to IOUS findings were noted.

RESULTS

IOUS supplied additional information in the case of 31 patients. In 28 of these patients, this information had a major impact on the intra-operative strategy, in that the procedure was altered.

CONCLUSIONS

IOUS is safe, simple to perform and more accurate than pre-operative imaging. It reduces the number of patients subjected to superfluous surgery. The use of IOUS is therefore encouraged during colorectal cancer surgery.

Regeneration after two-stage hepatectomy vs. repeat resection for colorectal metastasis recurrence

BACKGROUND

Two-stage hepatectomy aims to minimize liver failure risk by performing a second resection after regeneration, assuming that remnant liver hypertrophy after the second resection is similar to that seen in repeat hepatectomy, yet the impact of a two-stage strategy on liver volume and function remains to be demonstrated.

PATIENTS AND METHODS

Twenty patients undergoing two-stage hepatectomy for multiple colorectal cancer metastases and 21 patients with more than two sections of liver parenchyma totally removed by repeat liver resections for recurrence were enrolled. Liver volumes after final hepatectomy and postoperative liver function were compared.

RESULTS

Median total liver volumes before initial hepatectomy and after final hepatectomy of multiple resections were 942 and 863 ml in patients with repeat hepatectomy, whereas volumes at corresponding time points were 957 and 777 ml in patients with two-stage hepatectomy. The ratio of total liver volume after both hepatectomies to preoperative volume in the two-stage group (81.7%) was lower than that in the repeat resection group (92.0%, P = 0.027). Greater aspartate aminotransferase and prothrombin time and lower platelet count 1 month postoperatively and lower albumin at 6 months were evident after two-stage hepatectomy compared with repeat hepatectomy.

CONCLUSIONS

Two-stage hepatectomy is characterized by diminished hepatic regenerative capacity and postoperative liver function.

Outcome following repeat liver resection for colorectal liver metastases

AIM

Our aim was to determine independent predictors of survival after second liver resection and to confirm whether the type of first resection influences survival after repeat resection.

METHODS

Fifty-four patients who underwent a second liver resection for colorectal liver metastases were analyzed. To find independent predictors of survival, possible prognostic factors regarding the primary tumor, and the first and second resections were used in the Cox regression analysis.

RESULTS

There were three postoperative deaths within 90 days of surgery. The 3- and 5-year overall survival rates were 53% and 46%, respectively. The size of the tumor (>50mm) (p=0.005), serum carcinoembryonic antigen level (>30microg/L) (p=0.002), and the presence of a positive surgical margin at the second resection (p=0.006) were independent predictors of poor survival following the second resection. The type of first resection was not associated with survival but was associated with the ability to achieve a histological negative surgical margin at the second liver resection (p=0.01).

CONCLUSION

Three independent predictors of survival were identified. Major initial liver resection was associated with a reduced ability to achieve surgical clearance at the second resection. For colorectal liver metastases, major resection should only be performed if a negative margin cannot be achieved by minor resection.

Reflexiones sobre 250 intervenciones de metástasis hepáticas de carcinoma colorrectal

INTRODUCTION

The best results in the treatment of colorectal cancer metastases to the liver are currently achieved with surgical resection performed under high quality standards. OBJECTIVES. To analyze the results and quality standards of the surgical treatment of colorectal cancer liver metastases in a referral liver unit over an 11-year period.

PATIENTS AND METHOD

From January 1995 to December 2005, 250 surgical interventions were performed in 221 patients diagnosed with colorectal cancer liver metastases, resulting in 201 hepatic resections.

RESULTS

Nineteen percent of patients were >/= 70 years old and comorbidity was present in 54%. Of the 201 hepatic resections, 8.5% were second resections. Major hepatectomy was performed in 39% of the patients. R0 resection was achieved in 85% of the patients. Blood transfusions were not required in 80% of the patients. The median length of postoperative stay was 6 days. Postoperative mortality was nil and morbidity was 19%. Morbidity was associated with the number of resected segments and the need for blood transfusion. The estimated 1-, 3- and 5-year cumulative survival rates were 96%, 69% and 52%, respectively, while estimated disease-free survival rates were 58%, 32% and 24%, respectively.

CONCLUSIONS

Resection of colorectal cancer liver metastases is an effective therapeutic alternative if high current quality standards are achieved.

Systematic review on safety and efficacy of repeat hepatectomy for recurrent liver metastases from colorectal carcinoma

BACKGROUND

We critically appraised the quantity and quality of current clinical evidence to demonstrate the efficacy and safety of repeat hepatectomy for recurrent colorectal liver metastases (CRLM).

METHODS

Electronic searches for relevant studies published in peer-reviewed medical journals on repeat hepatectomy for recurrent CRLM before January 2007 were performed on six databases. The quality of each included study was independently assessed. Clinical effectiveness was synthesized through a narrative review with full tabulation of results of all included studies.

RESULTS

Seventeen studies with more than 20 patients were included for quality appraisal and data extraction. All 17 included articles were observational cases series. The overall perioperative morbidity rate ranged from 7% to 30% and mortality rate varied from 0% to 5%. The overall median survival since the repeat hepatectomy ranged from 23 to 56 months, with 3- and 5-year survival of 24% to 68% and 21% to 49%, respectively. The median disease-free survival ranged from 9 to 52 months, with 3- and 5-year disease-free survival of 16% to 68% and 16% to 48%, respectively.

CONCLUSIONS

The current literature suggests that repeat hepatectomy is associated with a prolonged survival for recurrent CRLM and is justified in selected patients because there is a lack of evidence for effective alternative treatments.

Surgical approaches of resectable synchronous colorectal liver metastases: Timing considerations

AIM: To compare the safety and efficacy of simultaneous versus two stage resection of primary colorectal tumors and liver metastases.

METHODS: From January 1996 to May 2004, 103 colorectal tumor patients presented with synchronous liver metastases. Twenty five underwent simultaneous colorectal and liver surgery and 78 underwent liver surgery 1-3 mo after primary colorectal tumor resection. Data were retrospectively analyzed to assess and compare the morbidity and mortality between the surgical strategies. The two groups were comparable regarding the age and sex distribution, the types of liver resection and stage of primary tumors, as well as the number and size of liver metastases.

RESULTS: In two-stage procedures more transfusions were required (4 ± 1.5 vs 2 ± 1.8, pRBCs, P < 0.05). Chest infection was increased after the two-stage approach (26% vs 17%, P < 0.05). The two-stage procedure was also associated with longer hospitalization (20 ± 8 vs 12 ± 6 d, P < 0.05). Five year survival in both groups was similar (28% vs 31%). No hospital mortality occurred in our series.

CONCLUSION: Synchronous colorectal liver metastases can be safely treated simultaneously with the primary tumor. Liver resection should be prioritized over colon resection. It is advisable that complex liver resections with marginal liver residual volume should be dealt with at a later stage.

Surgery for colorectal liver metastases: expanding the boundaries but where have all the patients gone

AIM

To review and discuss the current strategies and controversies in the surgical management of colorectal cancer liver metastases.

METHODS

An analysis of indications, contraindications and scoring systems and concepts for expanding the indications for resection are discussed. The findings and discussion are related to our own experience, especially with radiofrequency assisted liver resection for colorectal cancer liver metastases.

RESULTS

Resection is the only management strategy that can potentially cure the patient. Certain controversies still exist, such as contraindications for surgery, timing of treatment of synchronous metastases, significance of extra-hepatic disease etc. Strategies that can improve respectability are discussed. Parenchyma oriented, tissue sparing surgery facilitates reresection should it become necessary.

CONCLUSION

The management of colorectal cancer liver metastases is still a confusing issue for general oncologists and general surgeons. A multidisciplinary approach that tailors the management strategy to the individual patient is the only option that provides optimal results for patients with advanced disease.

Intrahepatic tumor recurrence after partial hepatectomy: value of percutaneous radiofrequency ablation

PURPOSE

To determine the risks and benefits of percutaneous radiofrequency (RF) ablation of recurrent hepatic tumors in patients who have undergone hepatic resection.

MATERIALS AND METHODS

Retrospective review of the institutional RF ablation database yielded 35 patients with recurrent hepatic tumor after hepatectomy. Sixty-one recurrent hepatic tumors (mean diameter +/- SD, 1.7 +/- 1.1 cm; range, 0.5-5.3 cm) were ablated percutaneously under sonographic guidance or combined guidance with sonographic and fluoroscopic computed tomography (CT). Follow-up CT, magnetic resonance imaging, or both were used for assessment of the primary and secondary therapeutic effectiveness rate and failure of RF ablation. Patients' survival status was determined by contacting the primary care physician or searching the Social Security Death Index.

RESULTS

Complete ablation was accomplished in 54 of 61 hepatic tumors (primary therapeutic effectiveness rate, 88.5%). During a mean follow-up time of 18 months (range, 1-65 months), 14.8% of the tumors (n = 9) were incompletely ablated. Three of the nine incompletely ablated tumors were treated with a second RF ablation, all three of which failed (secondary therapeutic effectiveness rate, 0%). Distant intrahepatic tumor progression appeared in 23 of 35 patients (65.7%). One major complication (2.1%, one of 48 sessions) and eight minor complications (16.7%, eight of 48 sessions) were reported. The major complication was hepatic abscess formation. The overall survival rates for all patients at 1, 2, and 3 years were 76%, 68%, and 45%, respectively. For patients with metastases from colorectal cancer (n = 14), the overall survival rates were 72%, 60%, and 60% at 1, 2, and 3 years, respectively; and for patients with hepatocellular carcinoma (n = 8), the overall survival rates were 72%, 58%, and 44% at 1, 2, and 3 years, respectively.

CONCLUSION

Percutaneous RF ablation offers a safe and effective treatment option for recurrent hepatic tumors after previous partial hepatectomy.

Meta-analysis of clinical outcome after first and second liver resection for colorectal metastases

BACKGROUND

The perioperative risk and long-term survival benefit of repeat hepatectomy for patients with liver metastases from colorectal cancer, compared with that of a first liver resection, has been reported with varying results in the literature.

METHODS

The literature was searched using Medline, Embase, Ovid, and Cochrane databases for all studies published from 1992 to 2006. Two authors independently extracted data using the following outcomes: postoperative complications and mortality; disease recurrence; and long-term survival. Trials were assessed using the modified Newcastle-Ottawa Score. Random-effect meta-analytical techniques were used for analysis.

RESULTS

Twenty-one studies met the inclusion criteria, comprising 3,741 patients. The use of adjuvant chemotherapy was similar in both groups (odds ratio [OR] = 0.97; 95% confidence interval [CI] = 0.54, 1.74; P = .92), as was the number of hepatic nodules present at the time of first or second resection (weighted mean difference [WMD] = 0.18; 95% CI = -0.22, 0.57; P = .380). Wedge resection was carried out less often at first hepatectomy (39% vs 46%; OR = 0.66; 95% CI = 0.44, 1.00; P = .05). There was significantly less blood loss in patients undergoing first versus second hepatectomy (WMD = 238 ml; 95% CI = 90, 385; P = .002). There was no difference in perioperative morbidity (OR = 1.01; 95% CI = 0.65, 1.55; P = .98), mortality (OR = 1.01; 95% CI = 0.18, 5.72; P = .99) or long-term survival (HR = 0.90; 95% CI = .66, 1.24; P = .530) between groups.

CONCLUSIONS

Repeat hepatectomy for patients with colorectal cancer metastases is safe and provides survival benefit equal to that of a first liver resection.

Second hepatectomy for recurrent colorectal liver metastasis: analysis of preoperative prognostic factors

BACKGROUND

Second hepatectomy is a potentially curative treatment for patients with hepatic recurrence of colorectal cancer. However, there is still no consensus about the patient selection criteria for second hepatectomy under these circumstances, and the factors affecting prognosis after second hepatectomy remain uncertain.

METHODS

Clinicopathologic data for 111 consecutive patients with colorectal liver metastasis who underwent second hepatectomy at a single institution between 1985 and 2004, and for whom complete clinicopathologic reports were available, were subjected to univariate and multivariate analyses.

RESULTS

The morbidity and mortality rates were 14% and 0%, respectively, and the overall 5-year survival rate was 41%. Multivariate analysis revealed that synchronous resection for the first liver metastasis (hazard ratio, 1.8), more than three tumors at the second hepatectomy (1.9), and histopathological involvement of the hepatic vein and/or portal vein by the first liver metastasis (1.7) were independently associated with poor survival. We used these three risk factors to devise a preoperative model for predicting survival. The 5-year survival rates of patients without any risk factors, and with one, two, or three risk factors, were 62%, 38%, 19%, and 0%, respectively.

CONCLUSIONS

Second hepatectomy is beneficial for patients without any risk factors. Before second hepatectomy, chemotherapy should be considered for patients with any of these risk factors, especially with two or three factors, in the adjuvant or neoadjuvant setting to prolong survival. These results need to be confirmed and validated in another data set or future prospective trial according to the scoring scheme we outline.

The Treatment of Hepatic Metastases in Colorectal Carcinoma

Colorectal carcinoma is the third most common cause of cancer death in the United States, with 135,000 new cases and 55,000 deaths annually. Ultimately, two-thirds (99,000) of all patients with colorectal cancer will develop metastasis to the liver and other organs in their life span, making metastatic colorectal cancer the second leading cause of cancer-related death in North America. The optimal management of these patients has become increasingly complex with the myriad of treatment options that are available. Because the timing of any therapy (surgery, chemotherapy, or others) has become integral to the success of the treatment, a collaborative approach involving multiple specialties is needed for the best patient outcome. Defined clinical and pathologic determinants of outcome have been demonstrated to effect the overall and disease-free survival of patients with metastatic colorectal cancer. Understanding of these determinants remains essential to any treating physician and has lead to significant paradigm shifts in the management of patients with metastatic colorectal cancer.

Survival after hepatic resection for colorectal metastases: a 10-year experience

BACKGROUND

Metastatic colorectal cancer is a major cause of cancer death in North America. Hepatic resection offers the potential for cure in selected patients. We report the long-term outcomes of patients who underwent hepatic resection for colorectal metastases over a 10-year period at a single hepatobiliary surgical oncology center.

METHODS

All patients who underwent liver resection for metastatic colorectal cancer between 1992 and 2002 were identified. Data were retrospectively obtained through chart review. Major outcome variables were disease-free survival and overall survival. Risk factors for disease recurrence and mortality were identified by multivariate analysis by using the Cox proportional hazard method.

RESULTS

A total of 423 hepatectomies were performed for metastatic colorectal cancer. Most operations (n = 276; 65%) were major (four or more segments) hepatectomies. Perioperative morbidity occurred in 74 (17%) patients. There were seven (1.6%) perioperative deaths. The disease-free survival at 1, 5, and 10 years was 64%, 27%, and 22%, respectively. The overall survival at 1, 5, and 10 years was 93%, 47%, and 28%, respectively. Multivariate analysis identified four negative predictive factors for overall survival (hazard ratio; 95% confidence interval): a positive surgical margin (2.9; 1.5-5.3), large metastases (>5 cm; 1.5; 1.1-2.0), multiple metastases (1.4; 1.1-1.9), and age >60 years (1.4; 1.1-1.9).

CONCLUSIONS

Hepatic resection for metastatic colorectal cancer is safe and provides good long-term overall survival rates of 47% at 5 years and 28% at 10 years. An aggressive approach is justified by the low operative mortality rate and good long-term survival, even in individuals with multiple bilobar metastases.

Repeat hepatectomy for recurrent colorectal liver metastases

PURPOSE

Liver resection represents the best and potentially curative treatment for metastatic colorectal cancer (MCC) to the liver. After resection, however, most patients develop recurrent disease, often isolated to the liver. The aim of this study was to determine the value of repeat liver resection for recurrent MCC and to analyze the factors that can predict survival.

PATIENTS AND METHODS

From January 1992 to October 2002, 42 patients from a group of 168 patients resected for MCC were submitted to 55 repeat hepatectomies (42 second, 11 third, and 2 fourth hepatectomies). Records were retrospectively reviewed. The primary tumor was carcinoma of the colon in 26 patients and carcinoma of the rectum in 16 patients. Liver metastases were synchronous in 24 patients (57.1%).

RESULTS

There were 25 men and 17 women with the mean age of 63.5 years (range: 34-80). There was no intraoperative or postoperative mortality. The morbidity rates were 9.5%, 14.3%, and 18.2% (P = 0.6) respectively after a first, second, or third hepatectomies. No patients needed reoperation. Operative duration was longer after a second or third hepatectomie than after a first hepatectomie without difference for operative bleeding. Overall 5-year survivals were 33%, 21%, and 36% respectively after a first, second, or third hepatectomies. Factors of prognostic value on univariate analysis included serum carcinoembryonic antigen levels (P = 0.01) during the first hepatectomy, the presence of extrahepatic disease (P = 0.05) and tumor size larger than 5 cm (P = 0.04) during the second hepatectomie.

CONCLUSIONS

Repeat hepatectomies can provide long-term survival rates similar to those of first hepatectomies.

The impact of advanced age on hepatic resection of colorectal liver metastases

BACKGROUND

The aim of this study was to evaluate the impact of patient age on surgical therapy for colorectal liver metastases.

STUDY DESIGN

Between 1992 and 2004, 212 consecutive patients underwent potentially curative hepatic resection. Sixty-two patients were 70 years or older at the time of resection (older group) and 150 patients were less than 70 years at the time of resection (younger group).

RESULTS

A proportion of older patients had a history of severe cardiopulmonary disease (32.3%) and respiratory insufficiency (6.5%). Intraoperative variables, such as resected liver volume, operation time, estimated blood loss, and blood transfusion, were not notably different between older and younger patients. Postoperative complications after resection occurred in 19.7% of older patients and at a similar rate (23.3%) in the younger group. Resection mortality was 0% in older patients and 0.49% in younger patients. The 5-year survival rates of older and younger patients were 34.1% and 53.1%, respectively. Compared with younger patients, the overall survival rate of older patients was markedly lower (p<0.01).

CONCLUSIONS

Advanced chronologic age cannot be regarded as a medical contraindication for hepatic resection of colorectal liver metastases in patients who are more than 70 years of age.

Detection of liver metastases: gadobenate dimeglumine-enhanced three-dimensional dynamic phases and one-hour delayed phase MR imaging versus superparamagnetic iron oxide-enhanced MR imaging

The aim of this study was to compare the diagnostic performance of gadobenate dimeglumine (Gd-BOPTA)-enhanced MR imaging, including dynamic phases and one-hour delayed phase, versus superparamagnetic iron oxide (SPIO)-enhanced imaging for detection of liver metastases. Twenty-three patients with 59 liver metastases underwent Gd-BOPTA-enhanced MR imaging (unenhanced, arterial, portal, equilibrium and one-hour delayed phase) using three-dimensional volumetric interpolated imaging and SPIO-enhanced T2-weighted turbo spin-echo and T2*-weighted gradient-echo sequences on a 1.5-T unit. Three observers independently interpreted the three sets of images, i.e. Gd-BOPTA-enhanced dynamic MRI (set 1), delayed phase imaging (set 2) and SPIO-enhanced MRI (set 3). Diagnostic accuracy was evaluated using the alternative-free response receiver operating chracteristic (ROC) analysis. Sensitivity and positive predictive value were also evaluated. The mean accuracy (Az values) and sensitivity of Gd-BOPTA-enhanced delayed phase imaging (0.982, 95.5%) were comparable to those of SPIO-enhanced imaging (0.984, 97.2%). In addition, Az values and sensitivities of both imaging sets were significantly higher than those of Gd-BOPTA-enhanced dynamic images (0.826, 77.4%: p<0.05). There was no significant difference in the positive predictive value among the three image sets. Gd-BOPTA-enhanced delayed phase imaging showed comparable diagnostic performance to SPIO-enhanced imaging for the detection of liver metastases, and had a better diagnostic performance than Gd-BOPTA-enhanced dynamic images.